Alternate Submission Form

Please submit the following information
Your First Name*
Your Last Name*
Your Company*
Your Email Address*
Full Name of Claimant*
Claim File Number*
Claimant Address - Please include City/State/Zip
Claimant Phone (if known)
Date of Incident*
Date Format: MM slash DD slash YYYY
Claimant DOB
Date Format: MM slash DD slash YYYY
Full SSN
Claimant Occupation
Description of Incident*
I have a photo or doc with additional file information
Select Services -- Choose any Combination
- Social Media with Scan Now
- Medical Canvass
- Criminal Records Search
- 1 Day Physical Surveillance
- 2 Days Physical Surveillance
- 3 Days Physical Surveillance
- 4 Days Physical Surveillance
- 5 Days Physical Surveillance
Anything Else?
Notes to the Investigator
Comments
This field is for validation purposes and should be left unchanged.